interference in personal lives and in business and marketing practices? Few quantitative data exist to answer these questions or to assert that these characteristics actually occur more commonly among Americans than among people in other countries.4 Nor is it reasonable to apply a stereotype to an entire society, especially one with the demographic, geographic, and cultural diversity of the United States. Still, for a variety of social or historical reasons, these values have salience for a large segment of U.S. society and may be important in understanding the pervasiveness of the U.S. health disadvantage.

The nature of the interaction between the free market economy and consumer preferences may also be somewhat distinctive in the United States. Manufacturers and other businesses cater to consumer demand for products and services that may not optimize health (e.g., soft drinks and large portion sizes) or, as in the case of cigarettes, are dangerous (Brownell and Warner, 2009). The tobacco industry’s long success in manufacturing and marketing products that have been known for five decades to cause cancer and other major diseases (Kessler, 2001; Lovato et al., 2003) reflects, in part, a symbiotic interdependence between producers and consumers who want (or are addicted to) the products.

Another systemic explanation considered by the panel is whether there is something unique in how decisions are made in the United States, in contrast with other countries, which might produce different policy choices that affect health. Not all of the problems identified in this report are affected by policy decisions—many relate to individual choices or perhaps the inherent nature of life in America—but decisions by government and the private sector may play a role in shaping many of the health determinants discussed throughout this report.

The relevance of public policy to health is perhaps most conspicuous in relation to recognized problems in the U.S. health care system—-limited access, especially for people who are poor or uninsured; fragmentation, gaps, and duplication of care; inaccessibility of medical records; and misalignment of physician and patient incentives (Institute of Medicine, 2001, 2010)—and the policies that are designed to address them. But the potential causes of the U.S. health disadvantage go beyond health care practice and policy. People are responsible for their individual behaviors, but individual life-styles are also influenced by the policies adopted by communities, states, and national leaders (Brownell et al., 2010). Cigarette

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4However, there is qualitative evidence regarding these characteristics from research in political science, anthropology, and other social science disciplines.